(608) 266-1311 | 1-800-WIS-VETS (947-8387)
APPLICATION FOR COUNTY VETERANS SERVICE GRANT
The information requested on this form is authorized for collection by Ch.45, Wis. Stats. and VA8.02, Wis. Adm. Code. The information collected is used to determine eligibility for programs administered by the department. Completion of this form is voluntary; however, failure to furnish the requested information may result in denial of eligibility for programs. Personally identifiable information collected on this form is not likely to be used for any other purpose.
This department does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability in employment or provision of services.
Pursuant to Wis. Stats. § 45.82(1), / County, hereby applies
for a County Veterans Service Grant for the Fiscal Year beginning / January 1, 2018 / , and ending
December 31, 2018 / , for the purpose of extending and strengthening service of veterans of this county.
Personnel now employed, with / 2018 / salary, to operate this County Veterans Service office are:
Job Title / Salary
County Veterans Service Officer / $
(Choose one: Full-Time Part-Time)
Others: (Insert County Job Title)
$
$
$
$
(List any added positions proposed for the office for the coming Fiscal Year, with salaries.)
Unless this application is solely for the part-time grant of $500, it is hereby agreed by the County Board ofCounty that the CVSO will be employed full-time in that position.
That, as a minimum condition, the County Veterans Service Office in this County will be maintained, open and staffed during normal county office hours; and
That the CVSO will be authorized to attend County Veterans Service conferences, institutes and all workshops and training sessions conducted by the Wisconsin Department of Veterans Affairs or the U.S. Department of Veterans Affairs as a regular part of his or her duties and will be provided equitable allowance or reimbursement for all necessary travel required in veterans service at the same rate all other county employees are paid.
That the grant received will not be allocated “for use by another county department nor may the county reduce funding to a county veterans service office based upon receipt of a grant” (Wis. Stats. § 45.82(2)). Grant funds shall be maintained in a separate account subject to audit by the Wisconsin Department of Veterans Affairs.
County Veterans Service Officer / Chairperson, County Board or other official designated to sign for the CountyPlease submit with this application (WDVA 0055B) a certified copy of the budget adopted by the county board for county veterans service office operation for calendar year 2018 to include the proposed use of the fiscal year 2018 county veterans service grant (sample format attached), grant agreement (WDVA 0055C), federal benefits service delivery report (WDVA 0055D), statement in the application cover letter which addresses success in meeting the previous year goals and objectives (if applicable) and include the goals and objectives for this grant period and letter from the county executive, administrator or administrative coordinator, to certify that it employs a county veteran service officer, appointed under civil service procedures in accordance with Wis. Stats. § 45.82(2) and/or Act 150 (i.e., Wis. Stats. § 230.15).
WDVA XXXX (02/07) Page 2 of 4 You can print the most recent version of this form
W:\Templates\WDVA_0000.dot from the WDVA website at www.WisVets.com/Forms.
/ 201 West Washington Avenue, P.O. Box 7843, Madison, WI 53707-7843(608) 266-1311 | 1-800-WIS-VETS (947-8387)
GRANT AGREEMENT
BETWEEN THE STATE OF WISCONSIN, DEPARTMENT OF VETERANS AFFAIRS
AND COUNTY VETERANS SERVICE OFFICER
This agreement is made and entered into effect this / 1st / day of / January / , / 2018 / ,
between the Department of Veterans Affairs (hereinafter referred to as the “Department”), the County of
and the / County Veterans Service Officer
(hereinafter referred to as the CVSO).
The CVSO shall file a grant application with the Department of Veterans Affairs for the current fiscal year, which shall include a certified copy of the budget adopted by the county board for county veterans service office operation for calendar year 2018 to include the proposed use of the fiscal year 2018 county veterans service grant (sample format attached), grant agreement (WDVA 0055C), federal benefits service delivery report (WDVA 0055D), statement in the application cover letter which addresses success in meeting the previous year goals and objectives (if applicable) and include the goals and objectives for this grant period and letter from the county executive, administrator or administrative coordinator, to certify that it employs a county veteran service officer, appointed under civil service procedures in accordance with Wis. Stats. § 45.82(2) and/or Act 150 (i.e., Wis. Stats. § 230.15).
The attached statement of goals and objectives for / January 1, 2018 / through / December 31, 2018
is a part of this agreement. The CVSO agrees to provide the Department with relevant information pertaining to the achievement of those goals and objectives. Grant funds shall be maintained in a separate account subject to audit by the Wisconsin Department of Veterans Affairs.
The provision of services to former military personnel, dependents and survivors covered by this agreement shall be from
January 1, 2018 / through / December 31, 2018 / .
The Department shall pay the CVSO’s county the entire grant to which the CVSO’s county is entitled under Wis. Stats. Wis. Stats. §45.82 provided the CVSO and the CVSO’s county have abided by the terms and conditions of this agreement.
STATE OF WISCONSIN / COUNTY OF
DEPARTMENT OF VETERANS AFFAIRS / STATE OF WISCONSIN
BY: / BY:
James Bond
Division Administrator
Division of Veterans Benefits
CVSO
WDVA XXXX (02/07) Page 3 of 4 You can print the most recent version of this form
W:\Templates\WDVA_0000.dot from the WDVA website at www.WisVets.com/Forms.
/ 201 West Washington Avenue, P.O. Box 7843, Madison, WI 53707-7843(608) 266-1311 | 1-800-WIS-VETS (947-8387)
COUNTY VETERANS SERVICE GRANT — FEDERAL BENEFITS SERVICE DELIVERY REPORT
The information requested on this form is authorized for collection by Ch.45, Wis. Stats. and VA8.02, Wis. Adm. Code. The information collected is used to determine eligibility for programs administered by the department. Completion of this form is voluntary; however, failure to furnish the requested information may result in denial of eligibility for programs. Personally identifiable information collected on this form is not likely to be used for any other purpose. This department does not discriminate on the basis of race, color, national origin, sex, religion, age, or disability in employment or provision of services.
Report for calendar Year / 2017 / ; FOR / CVSO
From / January 1, 2017 / , to / December 31, 2017
FEDERAL BENEFITS
ACTIVITY / NUMBER / COMMENTS1. / Power of Attorney Indicate the number of new VA Form 21-22s submitted to WDVA/Other VSOs for representation / /
2. / Disability Compensation Indicate the number of new VA Form 21-526s reconsiderations VA 21-526 or 21-527 or other communications submitted for compensation benefits to WDVA/VA or other VSO
3. / Pension Indicate the number of VA Form 21-527s or other communications submitted for veterans Pension benefits to WDVA/VA or other VSO
4. / Medical Expenses for Pension Indicate the number of VA Form 21p-8416s submitted for Unreimbursed Medical Expenses for pension and death pension to WDVA/VA or other VSO
5. / Loan Guaranty Indicate the number of Federal Home Loan applications submitted
6. / Educational Indicate the number of Federal Educational benefit applications submitted
7. / Vocational Rehabilitation Indicate the number of Federal VocRehab applications submitted
8. / Medical Indicate the number of VA Form 1010EZ forms submitted for enrollment into VA Healthcare
9. / USDVA Notice of Disagreement Indicate the number of Notice of Disagreements, VA Form 21-0958, DRO Request forms submitted to WDVA/VA or other VSO
10. / USDVA Waiver Requests Indicate the number of requests for waivers of Federal benefits regulations submitted
11. / BVA Appeals Indicate the number of VA Form 9s submitted to WDVA/VA or other VSO
12. / Insurance Indicate the number of applications for VA Insurance programs submitted
13. / Burial Allowances Indicate the number of applications for VA Burial Allowance submitted
14. / Flag Applications Indicate the number of applications submitted for Burial Flags
15. / Marker Applications Indicate the number of applications submitted for Burial Markers
16. / DIC Indicate the number of applications for Dependency and Indemnity Compensation, VA Form 21-534, submitted to WDVA/VA or other VSO
17. / Survivor’s Pension Indicate the number of applications for VA Death Pension, VA Form 21-534, submitted to WDVA/VA or other VSO
18. / Discharge Correction Indicate the number of applications for discharge upgrades submitted
19. / Miscellaneous Indicate the number of applications for other federal benefits, not listed, submitted by your office. Include types in comments.
WDVA 0055D (11/17) You can access the most recent version of this form from the WDVA
W:\Templates\WDVA_0055D_CVSO_Grant_Federal_Benefits_Report.doc website at http://dva.state.wi.us/Pages/newsmedia/WDVAToolkit.aspx
COUNTY VETERANS SERVICE OFFICE GRANT
PROPOSED BUDGET FORMAT
[Grant Year]
[County Name] COUNTY
GRANT AMOUNT: $13,000 [Example]
Proposed Budget / TimeFrame
Advertising of Veterans Programs and CVSO office (general) / $ 680.00 / Monthly
WDVA Targeted Initiative: Outreach
Promotion of WDVA benefits, program and services / $ 600.00 / Jan-Mar
Veterans Benefits and Job Fairs / $ 920.00 / May or October
Homeless Veterans Initiative / $ 400.00 / Spring
Veterans Homes / $ 600.00 / March
$ 2,520.00
Pre-Registration Programs:
State Veterans Cemeteries (King, Northern, Southern) / $ 1,000.00 / Ongoing
Veterans Homes (Chippewa Falls, King, Union Grove) / $ 900.00 / Ongoing
$ 1,900.00
WDVA or VA Conference and Training Cost / $ 300.00 / Spring, Fall
Develop relationships with community agencies offering benefits needed by veterans (employment, rehabilitation, counseling, emergency needs) / $ 900.00 / Ongoing
Office Expenses (Related to CVSO Grant Administration):
Copier Lease / $ 500.00
Computer Support / $ 700.00
Postage for Outreach to Veterans / $ 500.00
$ 1,700.00
Education and Training outreach for employed veterans at risk of losing their jobs / $ 500.00 / Jan-Jul
Publicity of Federal Compensation and Pension Benefits / $ 500.00 / Quarterly
Cost of Transportation for Veterans to VA Appointments / $ 500.00
Cost of Transportation of Personnel to WDVA/VA Training / $ 500.00
Supplemental Salary of CVSO Staff / $ 3,000.00 / Ongoing
TOTAL / $ 13,000.00
WDVA 0055E (11/17)
W:\Templates\WDVA_0055E_CVSO_Grant_Budget_Format_Sample.doc